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 Table of Contents  
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 1-3

Role of airway societies in improving airway management

1 Retired Head of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India
2 Consultant Anaesthetist, Ninewells Hospital, Dundee, Scotland; Difficult Airway Society, UK
3 Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
4 Department of Anesthesia and Intensive Care AOU Policlinico San Marco - Catania (Italy); European Airway Management Society (EAMS), Gainesville, Florida, USA
5 Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA

Date of Submission04-Mar-2022
Date of Acceptance05-Mar-2022
Date of Web Publication31-Mar-2022

Correspondence Address:
Dr Venkateswaran Ramkumar
“Prakrithi”, D/95-A, Ananthnagar 2nd Stage, Manipal - 576 104, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_6_22

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How to cite this article:
Ramkumar V, McGuire B, Myatra SN, Sorbello M, Urdaneta F, Divatia JV. Role of airway societies in improving airway management. Airway 2022;5:1-3

How to cite this URL:
Ramkumar V, McGuire B, Myatra SN, Sorbello M, Urdaneta F, Divatia JV. Role of airway societies in improving airway management. Airway [serial online] 2022 [cited 2023 Feb 1];5:1-3. Available from: https://www.arwy.org/text.asp?2022/5/1/1/342368

Over the past four decades, airway practitioners, anaesthetists in particular, have increasingly appreciated the need to consider best practices in airway management and to formulate guidance based on the available evidence to assist airway practitioners in their practice. This guidance is multifaceted involving recommended priorities, techniques, approaches and behaviours, presented in text and algorithms or pictorially as diagrams. The aim is to facilitate a safe, effective and consistent practice that can be taught, rehearsed and employed in various challenging airway management scenarios, including those of extreme urgency.

When faced with an anticipated difficult airway, the airway practitioner has time for planning, including making the desired equipment or expertise available. Literature is replete with recommendations for the management of different types of anticipated airway difficulty. On the other hand, an unanticipated difficult airway requires time-sensitive actions which may result in a potentially life-threatening situation if delayed or performed inappropriately. Most international airway societies have therefore focussed on guidelines for the unanticipated difficult airway, addressing issues related to technical and non-technical skills.[1],[2],[3],[4],[5],[6],[7],[8] While the fundamental principles and approaches to these guidelines are quite similar, there are differences in the structure of the algorithms, tools recommended or the number of attempts proposed for various interventions which may lead to a degree of confusion, obscuring the underlying principles that are common to all. The forthcoming Project for Universal Management of Airways (PUMA) guidelines aim to provide a comprehensive approach to airway management that airway practitioners can uniformly apply globally, independent of their clinical background, location or the clinical situation in which airway management is required.[9] While all guidelines must necessarily follow generic, established scientific principles and be evidence based, we feel it is essential to have country-specific guidance to account for variations in healthcare systems, such as the expected availability of items of airway equipment or the expertise to use a specialised technique. Although practice guidelines need to be specific, they should only be considered as advisory and should not be enforced as a standard of care. The guidance needs to be adapted to the resources available. For instance, while videolaryngoscopy may be the recommended approach in a country with good access to advanced devices, non-availability of the device may preclude its use as equipment of choice in another country with fewer resources. Classic examples are the availability (or non-availability) of essential bedside devices such as a pulse oximeter or a capnograph.[10] Unimaginable as it may seem to airway practitioners from high-income countries, this is the situation in many countries with limited resources. The All India Difficult Airway Association (AIDAA) Guideline on managing the unanticipated difficult airway does recommend using waveform capnography to confirm tracheal intubation.[6] Many other guidelines address a similar message, given that the scientific basis for capnography is undisputable. Where capnography is just not available, failure to use it cannot be considered a negligent deviation from the guideline. We believe that scientific evidence and the message from airway management guidelines such as the AIDAA Guideline and the forthcoming PUMA,[6],[9] should spur hospitals to ensure the availability of capnography for airway management. This is also the effort and the aim of the World Federation of Societies of Anaesthesiologists with the Global Capnography Project (GCAP).[11]

If one were to focus on the role that national societies play in airway management, it could be argued that creating workable practice guidelines is a relatively easy job and that the real challenge is ensuring effective widespread adoption and implementation of the recommendations into clinical practice. Indeed, many countries do not have focussed training programmes that facilitate the acquisition of knowledge and skills in airway management. While some residency programmes ensure that the logical reasoning behind escalation/de-escalation of airway interventions is taught, they do not emphasise the need to acquire knowledge, hands-on skills and effective behaviours required to execute such airway management plans. Many institutions will not have all the equipment that may be required. Familiarity with the difficult airway algorithms, including the various time-sensitive actions required, will be helpful to the airway practitioner when faced with an unanticipated difficult airway. How effectively and safely a resident will respond when faced with an airway emergency is best taught under simulated conditions. Unfortunately, medical simulation is often not available in many less-developed countries. Therefore, national societies need to authoritatively state that certain tenets of knowledge and skills related to airway management must be mandatorily acquired before completing residency.

Knowledge and skills acquisition should be central to the training of anaesthetists and other airway managers such as intensivists, emergency physicians and trauma surgeons. What better platform could one think of than the leaders of national airway societies liaising with governmental authorities and medical regulatory bodies (such as the National Medical Commission in India or equivalent bodies in other countries) to ensure that airway management is included in the course curricula? Exit examinations from Residency Programmes should have the Course Director certify the competencies of the resident. The community of teachers and airway experts needs to put their minds to the widespread adoption of safe airway management practices. National societies of professionals dealing with airway management are uniquely positioned to lobby with government departments, ministries, accreditation agencies and regulatory bodies to ensure that safe airway management practices are mandated in healthcare institutions.

Another aspect of the role of national societies is determining the incidence, causes and outcomes of difficult airway management. In this respect, the Fourth National Audit Project (NAP4) has indeed been a gift to all airway practitioners.[12] This report presents an in-depth analysis of 184 major airway-related events in the United Kingdom over 1 year. One hundred and thirty-three of these events occurred in the setting of anaesthesia. In contrast, the remaining 36 and 15 occurred in the intensive care unit and emergency department respectively (though with different denominators). The NAP4 document serves as an invaluable reference for future generations so that the recurrence of such events is minimised. Few other comprehensive documents analyse the causes of potentially life-threatening airway events. The Closed Claims Project (American Society of Anesthesiologists, USA) has also provided insights into airway events that resulted in morbidity or mortality.[13] An exercise involving collecting data regarding airway-related events needs the full cooperation of all concerned. Even though a national body may request for voluntary reporting of potentially life-threatening airway events, the hesitancy on the part of the 'reporter' is understandable. National societies should facilitate discussions at their scientific meetings on these airway events from published literature and from individuals willing to share such experiences. Sharing and discussing such incidents is a great educational tool. How often have we heard our teachers say, 'I cannot live long enough to experience all the mistakes that I can make'. Logical as this may seem, such exercises are likely to be patchy and incomplete to provide the basis for a definitive action plan.

Future efforts in airway management education must focus not only on the mandatory acquisition of basic and advanced airway skills but also on developing non-technical skills and principles of teamwork using the powerful simulation tool.[14] The value of this combined approach has been recently appraised in the fight against COVID-19 where airway management has been both a source of complications for the patient and a potential source of infection for airway managers.[15],[16] Finally, airway leaders should promote a no-blame culture, addressing the importance of biases and human error in understanding the mechanisms of failure to help improve the safety of our practice.

With world leaders in airway management behind this Editorial, one can hope that national societies from each country will talk to each other and agree on joint actions to improve airway management safety worldwide. The Global Oximetry Initiative, initiated by the World Health Organization, is one such global venture to make pulse oximeters available to recently developed and developing countries.[17] If one has to make patient care safe in hospitals, initiatives of this kind are the need of the hour. Similar initiatives could be made to make stand-alone capnography and airway equipment such as videolaryngoscopes available to those countries that do not have them. The GCAP, such as the one launched in Malawi, Africa, is needed in many countries.[11] It is the responsibility of well-placed societies to create a common communication platform with those societies in less-affluent countries for such thoughts to become a reality.

Although most airway societies have been doing their bit over the past few decades, it is time for us to take a realistic stock of the situation and see where we stand. An honest appraisal and follow-up action would make airway management in the hospital and prehospital environment much safer for our patients in the years to come.

  References Top

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Frova G, Sorbello M. Algorithms for difficult airway management: A review. Minerva Anestesiol 2009;75:201-9.  Back to cited text no. 2
Japanese Society of Anesthesiologists. JSA airway management guideline 2014: To improve the safety of induction of anesthesia. J Anesth 2014;28:482-93.  Back to cited text no. 3
Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115:827-48.  Back to cited text no. 4
Piepho T, Cavus E, Noppens R, Byhahn C, Dörges V, Zwissler B, et al. S1 guidelines on airway management: Guideline of the German Society of Anesthesiology and Intensive Care Medicine. Anaesthesist 2015;64 Suppl 1:27-40.  Back to cited text no. 5
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.  Back to cited text no. 6
[PUBMED]  [Full text]  
Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: Part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth 2021;68:1405-36.  Back to cited text no. 7
Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology 2022;136:31-81.  Back to cited text no. 8
Chrimes N, Higgs A, Law JA, Baker PA, Cooper RM, Greif R, et al. Project for Universal Management of Airways – Part 1: Concept and methods. Anaesthesia 2020;75:1671-82.  Back to cited text no. 9
Divatia JV. Safe anaesthesia for all Indians: A distant dream? Indian J Anaesth 2017;61:531-3.  Back to cited text no. 10
[PUBMED]  [Full text]  
Jooste R, Roberts F, Mndolo S, Mabedi D, Chikumbanje S, Whitaker DK, et al. Global Capnography Project (GCAP): Implementation of capnography in Malawi – An international anaesthesia quality improvement project. Anaesthesia 2019;74:158-66.  Back to cited text no. 11
Cook TM, Woodall N, Frerk C. Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Major complications of airway management in the United Kingdom, Report and findings. March 2011;1-219.  Back to cited text no. 12
Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: A Closed Claims Analysis. Anesthesiology 2005;103:33-9.  Back to cited text no. 13
Sorbello M, Afshari A, De Hert S. Device or target? A paradigm shift in airway management: Implications for guidelines, clinical practice and teaching. Eur J Anaesthesiol 2018;35:811-4.  Back to cited text no. 14
Sorbello M, Morello G, Pintaudi S, Cataldo R. COVID-19: Intubation kit, intubation team, or intubation spots? Anesth Analg 2020;131:e128-30.  Back to cited text no. 15
El-Boghdadly K, Wong DJ, Owen R, Neuman MD, Pocock S, Carlisle JB, et al. Risks to healthcare workers following tracheal intubation of patients with COVID-19: A prospective international multicentre cohort study. Anaesthesia 2020;75:1437-47.  Back to cited text no. 16
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